This thorough and impressive book is partly all about connection between people, and what happens when it's missing or faulty. Except that over-generalizes when generalization can be a problem in addressing issues such as depression, how it arises, what causes it, and how it can be treated. The contributors to this volume remind us that when looking at a person who is depressed, a wide range of factors must be taken into account, not only on a personal, individual level, but from a societal perspective: relationships, culture, education, work, generations, and gender, for example.

It springs from, and greatly expands, the work done by Dana Crowley Jack in developing the concept of self-silencing and its role in the development of depression in women. This work resulted in the important book Silencing the Self: Women and Depression, published in 1991. Silencing the Self Across Cultures still has a focus on women's experience of depression, but also includes work done on men's self-silencing, and questions raised about the different ways in which men and women silence their voices and what this silencing means for each.

The editors provide an overview of Silencing the Self Theory (STST). It postulates that women 'silence or suppress certain thoughts, feelings and actions that they think would contradict their partner's wishes', in order to avoid conflict and preserve the relationship, and/or ensure their psychological and/or physical safety within the relationship. This silencing of the voice leads to a loss of the sense of self, along with feelings of 'shame, desperation and anger over feelings of entrapment and self-betrayal'. This creates a 'vulnerability to depression by directing women to defer to the needs of others', so that women feel they're of less worth than others, they repress anger and censor the self, as well as 'inhibit self-directed action and judge the self against a culturally defined "good woman"' (5).

The Silencing the Self model integrates aspects of other psychological theories of depression, notably attachment, relational and cognitive, and emphasizes that relational disconnection and isolation are central to precipitating and maintaining depression.

The book is divided into three sections. The first is titled 'Setting the Stage: Social, Biomedical, and Ethical Issues in Understanding Women's Depression' and contains four chapters, including the introductory piece by the editors. The second is headed 'Self-Silencing and Depression Across Cultures' and has ten chapters with an introduction. It includes studies of women in Germany, Nepal, Finland, Poland, Portugal and Haiti, as well as the experiences of immigrant women, and a chapter on the meaning of self-silencing in both men and women. The third section is 'The Health Effects of Self-Silencing' and contains eight chapters with an introduction and commentary, and discusses feminism, HIV/AIDS, cancer, eating disorders, heart disease and the Framingham study, premenstrual syndrome, postpartum depression and abusive relationships. There is an Appendix which contains the Silencing the Self Scale for reference. Each chapter has extensive references, and there is an index at the end of the book.

Carol Gilligan provides a preface, in which she neatly states the contribution of this collection: 'by bringing cultural perspectives to the analysis of depression in women, they reveal the overarching framework of patriarchy. To see the framework, however, is also to reveal the possibility of shifting the frame' (xiii).

There are a number of highlights throughout this comprehensive title. Richard A Gordon notes that 'We may "listen" to Prozac, but Prozac does not talk' (68) in his chapter arguing that the biogenic (and popular) model of depression, with its consequent increase in the prescription of anti-depressant medication, ignores the social causes of depression (as well as the cultural, gender, ethnic etc). Linda Smolak concludes that we need more research to clarify the differences in male and female 'pathways to self-silencing', including the meaning and development of silencing. Each of the chapters examining women's depression in different countries reveals the importance of cultural and ethnic differences in both individual and social attitudes to gender roles and expectations, and Trimble et al in Chapter 4 emphasize the sensitivity needed in designing and carrying out research studies in different cultures.

Sikka et al describe the different ways in which men and women use self-silencing--baldly summarized as men to maintain power within the relationship and women to maintain the relationship--and noted that, within relationships, men tend to fulfill their needs whereas women tended to negate or at best negotiate theirs (269). Besser and her colleagues find that the STS model is associated with, not only depression, but also core personality traits that are associated with a vulnerability to depression, and that this combination increases the risk for increased psychological distress.

The section on health emphasizes the connection between chronic stress, anxiety and depression and poor physical health. There are complex interplays between mental and physical health, and relational and cultural expectations that the various authors tease out. The way in which the STS model can be shown to be relevant in these conditions is well explained and enlightening.

Stephanie J Woods in Chapter 22 makes the obvious but still startling reminder that human relationships both cause and heal self-silencing and violence (497): connection again, but it needs to be a positive connection, not a damaging one.

There is a lot to digest in this volume, but generally it is written in an approachable style, notwithstanding the statistical analyses in some chapters. The inclusion of narratives from women is welcome, giving voice to the research findings and providing a human, grounding touch. It is not written for the lay person, but more for practitioners, academics and researchers in the field.

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